RECOGNITION

  • Anaemia (WHO):
    • Hb <130 g/L in males
    • Hb <120 g/L in non-pregnant females
    • normal range for Hb includes patients who are anaemic
    • look for cause

Symptoms of anaemia

  • Patients may tolerate a very low Hb levels
    • do not base clinical decisions on Hb value alone

Severe

  • Heart failure symptoms
  • Chest pain

Moderate

  • Shortness of breath at rest
  • Palpitations

Mild

  • Fatigue
  • Shortness of breath on exertion

Specific symptoms for reduced folate

  • Reduced sense of taste
  • Diarrhoea
  • Numbness and tingling in the feet and hands
  • Muscle weakness
  • Depression 

Investigations

  • FBC
  • Folate
  • Serum cobalamin (B12) 

INITIAL MANAGEMENT

  • Serum folate <3 µg/L is indicative of folate deficiency
  • ‘False positive’ reduced folate in:
    • normal pregnancy,
    • anorexia,
    • acute alcohol consumption,
    • medications: anticonvulsant. Consult BNF

Precautions

  • Low folate may be with low serum cobalamin
    • if so, treat with B12 before commencing folic acid
  • If strong clinical suspicion of folate deficiency, despite a normal serum level;
    • exclude cobalamin deficiency
    • measure red cell folate assay

Assessment

  • Diet (most common cause)
  • Alcohol consumption
  • Gastrointestinal diseases e.g.
    • coeliac disease, IBD, liver disease, GI surgery
  • Pregnancy status
  • Exfoliative skin diseases
  • Renal dialysis
  • Medications
  • History/symptoms due to haemolytic anaemia

TREATMENT

  • Dietary sources of folate
    • asparagus, broccoli, brown rice
    • chickpeas, sprouts, peas
  • Follow schedules outlined in the BNF
  • Renal dialysis patients, follow renal protocols
    • note Renavit contains 1 mg folic acid. Give after dialysis.
    • excess folic acid may cause dynamic bone disease

RBC transfusion in chronic anaemia

  • Consider a single unit RBC transfusion in patients with:
    • moderate/severe symptoms
    • haemodynamically stable
    • reversible cause of anaemia
    • Hb <90 g/L
  • Remember each unit transfused is a treatment decision
  • See Chronic Anaemia: RBC transfusion 

ASSESSING RESPONSE

  • Monitor reticulocyte count and FBC parameters initially.
  • Monitor serum folate level as dictated by clinical indication

DISCHARGE

  • Inform GP of:
    • cause
    • treatment
    • monitoring required

© 2022 The Bedside Clinical Guidelines Partnership.

Created by University Hospital North Midlands and Keele University School of Computing and Mathematics.

Research and development team: James Mitchell, Ed de Quincey, Charles Pantin, Naveed Mustfa